Laparoscopic repair of paraesophageal hernia is safe and feasible and can provide comparable results for patients with type IV paraesophageal hernia. We report a rare case of mediastinal seroma in an 80-year-old gentleman who had a giant type IV paraesophageal hernia and was eventually admitted to our hospital for elective laparoscopic repair and recovered very well after surgery with resolution of the atelectatic lungs and air-fluid collection in his chest.

Type II to Type IV paraesophageal hernia (PEH) is a rare type of hiatus hernia with reported incidence of 2-5%.[1] Type IV is the least common, representing approximately 5-7% of all paraesophageal hernias.[2] Without surgical intervention, catastrophic complications including torsion, gangrene, perforation, and massive hemorrhage may occur and result in high mortality up to 26%. In recent years, laparoscopic repair of paraesophageal hernia became the operation of choice. It is a safe and feasible procedure with few minor complications. We report a rare case of mediastinal seroma following laparoscopic repair of large type IV paraesophageal hernia.

Case Report

An 80-year-old gentleman who had a long-standing history of chest pain, early satiety and shortness of breath especially after large meals presented to the emergency department with chest pain. Preoperative investigations included a chest X-ray which showed multiple fluid levels within the mediastinum [Figure 1], and an abdominal CT scan which showed a giant type IV paraesophageal hernia with most of the stomach and transverse colon herniated into the chest [Figure 2]. He was eventually admitted for elective repair of the large paraesophageal hernia.

The patient underwent a laparoscopic repair of his paraesophageal hernia using five-port incision. Pneumoperitoneum was established at the left upper quadrant. Gastrohepatic omentum was incised and the herniated stomach and colon were reduced into abdomen. The hernial sac was dissected from the mediastinum and then excised. Mediastinal dissection of the esophagus was done to obtain more intrabdominal length. The crura were closed primarily by using silk stitches. The fundus of the stomach was sutured to the right crus of the diaphragm. Gastropexy was done to prevent future herniation of the stomach. Surgery was uneventful until four days post-operation, when he started to complain of shortness of breath and a pressure sensation in his chest. At that time, his oxygen saturation was 95% with 3L of inspired oxygen per minute, respiratory rate of 24/min, heart rate of 110 bpm and BP of 127/74 mmHg. Chest examination revealed decreased air entry in the lower zone of both lungs. Blood works were all normal. Chest CT scan was done to rule out pulmonary embolism, which showed a large mediastinal seroma with surrounding atelectasis and anterior displacement of the mediastinal structure [Figure 3]. He was taken back to the operating room for left thoracoscopic drainage of his mediastinal seroma. Intraoperatively, we found a large cyst causing atelectasis of the lower lobe of the lung with anterior displacement of the mediastinal structures. We opened the mediastinal pleura above the cyst and drained around 450 cc of serosanginous fluid. Chest tube was inserted at the site of the sac. The patient recovered very well after surgery and was sent home with a follow up chest X-ray which showed resolution of the atelectatic lungs and air-fluid collection in his chest [Figure 4].

Complications following repair of PEH are usually minor and ranged from 8% to 28% in most large series. [3],[4],[5] Mediastinal seroma is a rare complication reported after repair of large paraesophageal hernias. [6] It is usually an incidental finding in patients who have had CT chest to rule out other causes of respiratory distress after surgery, such as pulmonary embolism. Failure to excise the hernial sac may be a major contributing factor to the seroma formation.[7] Sac excision eliminates the serous membrane lining the cavity in the mediastinum and reduces the chance of a symptomatic collection. Unmobilized sac can act as a lead point on the stomach and cause it to be pushed back into the chest.[8] In our case report, although the sac was excised, patient still developed a large symptomatic mediastinal seroma. This could be related to the significant atelectasis of the lung, which is not filling the space of the hiatus hernia, or to the tight crural closure preventing the drainage of the residual fluid into the peritoneal space. Complete sac excision, avoiding tight crural closure along with aggressive post-operative chest physiotherapy could prevent such complication in the future. Most patients with mediastinal seroma are asymptomatic and surgical intervention is unnecessary, but a few patients become symptomatic and require some form of percutaneous drainage.[9]